Chest Wall and Diaphragmatic Injuries

  • Filippo Antonacci
  • Stephane Renaud
  • Alessandra Mazzucco
  • Giulio Orlandoni
  • Nicola Santelmo


Thoracic trauma is the second leading cause of death in case of trauma, after head trauma. Rib fractures are one of the most common injuries affecting trauma patients, occurring in approximately 10% of all cases, and they are associated with a mortality of 3–13%. Frequent complications of this condition are pneumonia, prolonged ventilator time, prolonged hospitalization, and chronic debilitating pain. It has been shown that a greater number of rib fractures are associated with an increased risk of complications, particularly in older patients. Optimal treatment of rib fractures has not been established; in particular, the role of surgery is a matter of debate.

Diaphragmatic injuries have been reported in 0.8–20% of patients hospitalized for blunt trauma and in 3.4–47% of patients sustaining a penetrating thoracoabdominal trauma. Mechanism of injury may be dissipation of energy from the abdominopelvic cavity to the chest in case of blunt trauma or penetrating thoracoabdominal trauma. These result in a laceration of the diaphragm, causing a hernia, that can be diagnosed in the acute setting or remain silent for months or years.


  1. 1.
    Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, French B, Gasparri M, Marasco S, Minshall C, Sarani B, Tisol W, VanBoerum DH, White TW. Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury. 2017;48(2):307–21.CrossRefGoogle Scholar
  2. 2.
    Galvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, To KB, Fox AD, Alley DE, Ditillo M, Joseph BA, Robinson BR, Haut ER. Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936–51.CrossRefGoogle Scholar
  3. 3.
    Senekjian L, Nirula R. Rib fracture fixation: indications and outcomes. Crit Care Clin. 2017;33(1):153–65.CrossRefGoogle Scholar
  4. 4.
    Olland A, Renaud S, Reeb J, Guinard S, Jeitlinger J, Santelmo N, Falcoz PE, Massard G. Traitement chirurgical des traumatismes fermes du thorax et technique de l’osteosynthese costale. Encyclopedie Medico Chirurgicale, Techniques chirurgicales Thorax. 10.1016/S1241-8226(16)64626-1.Google Scholar
  5. 5.
    Kucharczuk JC, Cohen JE. Thoracic Trauma, Chapter 100. In Intensive Care Unit Manual, pp. 916–20.Google Scholar
  6. 6.
    Bailitz J, Hedayati T. Thoracic trauma. Emerg Med. 78:681–94.Google Scholar
  7. 7.
    Asensio JA, Trunkey DD. Thoracic injuries. In: Asensio JA, Trunkey DD, editors. Current therapy of trauma and surgical critical care. 2nd ed. New York: Elsevier; 2016. p. 205–28.Google Scholar
  8. 8.
    Bhavnagri SJ, Mohammed TL. When and how to image a suspected broken rib. Cleve Clin J Med. 2009;76(5):309–14.CrossRefGoogle Scholar
  9. 9.
    Davis S, Affatato A. Blunt chest trauma: utility of radiological evaluation and effect on treatment patterns. Am J Emerg Med. 2006;24(4):482–6.CrossRefGoogle Scholar
  10. 10.
    Peters S, Nicolas V, Heyer CM. Multidetector computed tomography-spectrum of blunt chest wall and lung injuries in polytraumatized patients. Clin Radiol. 2010;65(4):333–8. Epub 2010 Feb 12.CrossRefGoogle Scholar
  11. 11.
    Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. Am J Roentgenol. 1999;173(6):1603–9.CrossRefGoogle Scholar
  12. 12.
    Zaw AA, Murry J, Hoang D, Chen K, Louy C, Bloom MB, Melo N, Alban RF, Margulies DR, Ley EJ. Epidural analgesia after rib fractures. Am J Surg. 2015;81(10):950–4.Google Scholar
  13. 13.
    Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs—a pilot study. J Trauma. 2009;66(4):1096–101.CrossRefGoogle Scholar
  14. 14.
    Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M, Roccaforte DJ, Spector R. Pain management guidelines for blunt thoracic trauma; EAST Practice Management Guidelines Work Group. J Trauma. 2005;59(5):1256–67.CrossRefGoogle Scholar
  15. 15.
    Kerwin AJ, Haut ER, Burns JB, Como JJ, Haider A, Stassen N, Dahm P, Eastern Association for the Surgery of Trauma Practice Management Guidelines Ad Hoc Committee. The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S283–7.CrossRefGoogle Scholar
  16. 16.
    Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52:727–32; discussion 732.PubMedGoogle Scholar
  17. 17.
    Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4:583–7.CrossRefGoogle Scholar
  18. 18.
    Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216:924–32.CrossRefGoogle Scholar
  19. 19.
    Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest-outcomes of patients with or without pulmonary contusion. J Am Coll Surg. 1998;187:130–8.CrossRefGoogle Scholar
  20. 20.
    Blitz M, Louie BE. Chronic traumatic diaphragmatic hernia. Thoracic Surg Clin. 2009;19(4):491–500.CrossRefGoogle Scholar
  21. 21.
    Steyn E. Penetrating injuries to the diaphragm. In: Velmahos GC, Degiannis E, Doll D, editors. Penetrating trauma. Berlin: Springer; 2017.Google Scholar
  22. 22.
    Hanna WC, Ferri LE. Acute traumatic diaphragmatic injury. Thorac Surg Clin. 2009;19(4):485–9.CrossRefGoogle Scholar
  23. 23.
    Dante Yeh D, Lee J. Trauma and blast injuries. In: Robert Mason V, Broaddus C, Martin T, et al., editors. Murray and Nadel’s Textbook of respiratory medicine. 5th ed. Philadelphia: Saunders. p. 1354–66.Google Scholar
  24. 24.
    Dalshaug GB, Rothwell BC. Diaphragmatic paralysis following minor blunt trauma. J Trauma. 1999;47(2):413–5.CrossRefGoogle Scholar
  25. 25.
    Ko MA, Darling GE. Acquired paralysis of the diaphragm. Thorac Surg Clin. 2009;19(4):501–10.CrossRefGoogle Scholar
  26. 26.
    Groth AS, Andrade RS. Thoracic surgery clinics. Diaphragmatic Eventration. 2009;19(4):511–9.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Filippo Antonacci
    • 1
  • Stephane Renaud
    • 2
  • Alessandra Mazzucco
    • 1
  • Giulio Orlandoni
    • 1
  • Nicola Santelmo
    • 3
  1. 1.Department of Thoracic SurgeryFondazione IRCCS Policlinico San MatteoPaviaItaly
  2. 2.Department of Thoracic Surgery, Institut Lorrain Du Coeur Et Des Vaisseaux Louis MathieuNancy University HospitalNancyFrance
  3. 3.Department of Thoracic SurgeryStrasbourg University HospitalStrasbourgFrance

Personalised recommendations